![](https://static.wixstatic.com/media/78830b_3277280604db41fe8026c6d072f2e166~mv2.jpg/v1/fill/w_1920,h_1080,al_c,q_90,usm_0.66_1.00_0.01,enc_auto/78830b_3277280604db41fe8026c6d072f2e166~mv2.jpg)
Consent to Release Version 1.0
Electronic Funds Transfer (EFT) Authorization for Claim Payments Version 1.0
Guide to Applying for Freezing of Hours Version 1.0
Guide to Applying for Weekly Disability Benefits Version 2020
Health Spending Account Claim Form Version 1.0
Pre-Determination - Hospital Bed Assessment Form Version 2017
Pre-Determination - Knee Brace Version 2017
Pre-Determination - Nursing Care Assessment Form Version 2017
Pre-Determination - Oxygen Concentrator Assessment Form Version 2017
Pre-Determination - Wheelchair Assessment Form Version 2017
Prescription Drug Special Authorization Request Form Version 1.0
Consent to Release Version 1.0
Electronic Funds Transfer (EFT) Authorization for Claim Payments Version 1.0
Guide to Applying for Freezing of Hours Version 1.0
Guide to Applying for Weekly Disability Benefits Version 2020
Health Spending Account Claim Form Version 1.0
Pre-Determination - Hospital Bed Assessment Form Version 2017
Pre-Determination - Knee Brace Version 2017
Pre-Determination - Nursing Care Assessment Form Version 2017
Pre-Determination - Oxygen Concentrator Assessment Form Version 2017
Pre-Determination - Wheelchair Assessment Form Version 2017
Prescription Drug Special Authorization Request Form Version 1.0
Maintenance for Pharmacy Network and eClaims Provider
July 24, 2024
What does this mean for you?
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If you go to your pharmacy or eClaims provider on Sunday July 28th, 2024, from 3 a.m. to 3 p.m. Eastern Time, you must pay for your prescription drug or health claim out of pocket and manually submit your claim to Ellement.
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You will not be able to submit your prescription drug claim using the Ellement App on Sunday July 28th, 2024, from 3 a.m. to 3 p.m. Eastern Time. You will be able to submit your claims after this maintenance period.
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This does not affect dental claim submissions.
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Please contact us if you have any questions.